Director of Clinical Operations

COPE Health Solutions • New York, NY

4d • $165,000 - $215,000 • Hybrid

About The Position

The Director of Clinical Operations is a senior, hands-on leader responsible for overseeing day-to-day clinical and operational execution for UM and CM services across health plan, IPA, ACO and other clients as well as the CHS IPA/ACO. This role requires deep expertise in Utilization Management (UM), Care Management (CM), Quality, and clinical program implementation.
This individual operates with a high degree of autonomy, makes timely and confident decisions, and is deeply involved in operational details while maintaining accountability for outcomes, compliance, and client satisfaction in a fast-paced, high-growth environment.

Requirements

• Bachelor’s degree in nursing, Healthcare Management, or related field, or equivalent experience.
• 8–12+ years of progressive experience in Utilization Management, Medical Management, Clinical Operations, or Healthcare Operations, including senior leadership responsibilities.
• Deep, hands-on knowledge of UM operations, clinical criteria, and regulatory compliance.
• Experience leading client implementations and ongoing managed services in a health plan, TPA, MSO, consulting, or health tech environment.
• Proven ability to operate independently, manage ambiguity, and make timely, high-impact decisions.
• Strong experience developing operational workflows, performance metrics, and scalable processes.

Nice To Haves

• Clinical licensure (RN, MD, DO or equivalent) strongly preferred.
• Strong Health plan operations knowledge.
• Experience with Medicare, Medicaid, and/or commercial populations.
• Knowledge of delegated UM arrangements and audit processes.
• Experience working in or alongside technology-enabled clinical operations.

Responsibilities

• Provide direct oversight and operational leadership for Utilization Management and Care Management programs and activities, ensuring high-quality, compliance, and timely execution.
• Ensure consistent application of CM and UM policies, procedures, workflows, and evidence-based clinical criteria for UM (e.g., MCG, LCDs, NCDs, medical necessity guidelines).
• Monitor CM and UM program effectiveness and drive continuous improvement through data analysis, workflow optimization, and operational redesign.
• Serve as an escalation point for complex clinical determinations, operational issues, and regulatory concerns, making decisive, independent decisions as needed based on the clinical operations model for a particular client or the CHS IPA/ACO.
• Ensure all clinical operations comply with federal, state, and accreditation requirements, including delegated entity oversight and audit readiness.
• Lead end-to-end onboarding for new and existing clients, including project planning, timeline management, performance improvement and coordination with internal and external stakeholders.
• Ensure accurate setup of systems, workflows, and compliance requirements.
• Conduct pre- and post-implementation reviews to guarantee smooth transitions.
• Support quality improvement initiatives using objective and benchmark data, including utilization metrics, member outcomes, CAHPS, HEDIS, and Star Ratings where applicable.
• Develop, implement, and monitor robust operational, clinical, and outcome metrics across UM, Care Management, and implementation activities.
• Ensure services and deliverables are completed within expected timeframes and support internal and external quality audits.
• Drive operational excellence through process improvement, standardization, automation, and scalable infrastructure.
• Oversee clinical systems integrity, upgrades, customization, and reporting to ensure efficiency, data accuracy, and regulatory compliance.
• Develop, review, and maintain clinical and operational policies and procedures aligned with current practices and regulatory requirements.
• Partner with sales, clinical, operational, and IT teams to deliver consistent and exceptional client experience.
• Coordinate internal resources for operational support.

Benefits

• We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 51-100 employees